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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br /> printouts from tests(f applicable)should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: RAMOS OIL Date of Testing: 10/7/10 <br /> Facility Address: 10842 S.HARLAN ROAD, FRENCH CAMP, CA 95231 <br /> Facility Contact: DAVE NELSON Phone: (916)371-3289 <br /> Date Local Agency Was Notified of Testing: 9/29/10 <br /> Name of Local Agency Inspector(if present during testing): THUY TRAM <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANK-TEK ENVIRONMENTAL CORPORATION <br /> Technician Conducting Test: MIKE LAWRENCE <br /> Credentials': ® CSLB Contractor ® ICC Service Tech. ® SWRCB Tank Testerp(Specify) <br /> ❑ Other(S eci <br /> License Number(s): 803705(CSLB Contractor)—1048103-UT(ICC Service Tech.)—90-1200(SWRCB Tank Tester) <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ® Hydrostatic ❑ Vacuum ❑ Other(Spec) <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket(By Tank <br /> Number, Stored Product, etc.) DIESEL FILL <br /> Bucket Installation Type: ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> ® Contained in Sump ❑ Contained in Sump ❑ Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter: 11.50" <br /> Bucket Depth: 14.50" <br /> Wait time between applying 0 MIN <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 10:50 AM <br /> Initial Reading(RI): 13.00" <br /> Test End Time(TF): 11:50 AM <br /> Final Reading(RF): 11.00" <br /> Test Duration(TF—TI): 1 HR <br /> Change in Reading(RF-RI): 2.00" <br /> Pass/Fail Threshold or Criteria: +/-0.002" <br /> Test Result: ❑ Pass Z Fail ❑ Pass ❑ Fail ❑ Pass ❑Fail ❑ Pass ❑ Fair <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> DIESEL FAILED DUE TO LEAKS <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date: 10/7/10 <br /> ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br /> may be more stringent. <br />